CLAIM FOR DEATH BENEFITS

ICR 198312-1121-003

OMB: 1121-0024

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
120144 Migrated
ICR Details
1121-0024 198312-1121-003
Historical Active 198111-1121-002
DOJ/OJP
CLAIM FOR DEATH BENEFITS
Revision of a currently approved collection   No
Regular
Approved without change 01/30/1984
Retrieve Notice of Action (NOA) 12/19/1983
  Inventory as of this Action Requested Previously Approved
01/31/1987 01/31/1987 12/31/1983
320 0 320
336 0 336
0 0 0

THIS FORM INITIATES A CLAIM UNDER THE PUBLIC SAFETY OFFICERS' BENEFITS ACT OF 1976. THE FORM IS COMPLETED BY ONE OF THE DECENDENT OFFICER'S ELIGIBLE SURVIVORS. THE FORM AND DOCUMENTS PROVIDED BY THE SURVIVOR I USED TO IDENTIFY SURVIVORS AND DETERMINE THEIR ELIGIBILITY FOR BENEFIT

None
None


No

1
IC Title Form No. Form Name
CLAIM FOR DEATH BENEFITS OJARS/LEAA, 3650/1

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 320 320 0 0 0 0
Annual Time Burden (Hours) 336 336 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
12/19/1983


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